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Services That Require Pre-certification

 

The following services require benefit pre-certification prior to the service being rendered. Written guidelines for most of these services are referenced below.

 

Procedures requiring pre-certification

Advanced Imaging Studies, see the NIA website at RadMD.com

 

 

All stem-cell transplants require pre-certification

 

 

Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

 

Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder 

 

Bariatric Surgery

 

Bio-Engineered Skin and Soft Tissue Substitutes

 

Blepharoplasty and Repair of Blepharoptosis

 

Bone (Mineral) Density Studies

 

Brachytherapy, Noncoronary

 

Breast Pumps 

 

Bronchial Thermoplasty

 

Cardiac-Related Procedures

 

Carrier Testing for Genetic Diseases

 

Catheter Ablation as Treatment for Atrial Fibrillation

 

Charged-Particle (Proton or Helium Ion) Radiation Therapy

 

Chiropractic Services

 

Clinical Trials

 

Cognitive Rehabilitation Therapy (cognitive rehabilitation for patients with traumatic brain injury)

 

Complementary and Alternative Medicine (CAM)

 

Glucose Monitoring System

 

Cosmetic surgery or surgery that may possibly be considered cosmetic. HMSA plans do not cover cosmetic surgery primarily intended to improve a patient's appearance without restoring or materially improving a physical function, nor surgery prescribed for psychological or psychiatric purposes.

 

However, cosmetic surgeries that meet HMSA's guidelines (see Cosmetic and Reconstructive Surgery and Services) and that are appropriately documented are covered.

 

Examples of services that may be considered cosmetic are Reduction Mammaplasty for Breast-Related Symptoms and Blepharoplasty and Repair of Blepharoptosis.

 

Also see Panniculectomy/Abdominoplasty.

 

For a list of CPT procedure codes that may be considered cosmetic, see Cosmetic Procedures - Claim Documentation Requirements.

 

To request pre-certification of cosmetic surgery, contact the Pre-certification Unit.

 

Drugs Requiring Pre-certification

Injectables and Infused Drugs

Other FDA approved drugs. Please refer to FDA-Approved Drugs Requiring Pre-certification

 

Dietetic Treatment of Eating Disorders

 

Durable Medical Equipment, Prosthetics and Orthotics

 

Durable Medical Equipment, Prosthetics and Orthotics - Small Group & Individual Plans, Fed 87

 

Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

 

Gamma-knife surgery,see Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

 

Gender Identity Services

 

Gender Reassignment

 

Genetic Risk Assessment/Counseling - based on HMSA genetic testing policies for members who are being considered for genetic testing and are at high risk for the following conditions: breast cancer (BRCA), ovarian cancer (BRCA), familial adenomatous polyps (FAP), lynch syndrome (hereditary nonpolyposis colorectal cancer), attenuated familial adenomatous polyps (AFAP), MYH associated polyps (MAP).

 

Genetic Testing for Hereditary Breast and/or Ovarian Cancer

 

Genetic Testing for Lynch Syndrome/Colorectal Cancer and Polyposis Syndromes

 

Genetic Testing for Non-Cancerous Inheritable Diseases

 

Genetic Testing, Including Chromosomal Microarray Analysis and Next-Generation Sequencing Panels, for the Evaluation of Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and/or Congenital Anomalies

 

Growth Hormone Therapy

 

Habilitative Services

 

High Frequency Chest Wall Oscillation Devices

 

Home INR Monitor

 

Hospital admissions, The Federal Employee Program (FEP, enrollment codes 104, 105, 111 and 112) require pre-certification of hospital admissions and home hospice care. Pre-certification is not required for maternity admissions unless they exceed two days for vaginal deliveries or four days for cesarean section, or when FEP is secondary to Medicare. (See Federal Employee Program (FEP))

 

Hyperbaric Oxygen Pressurization (HBO)

 

Immune Globulin Therapy

 

Incontinence Supplies

 

Insulin Pumps - External

 

Intensity Modulated Radiation Therapy (IMRT)

 

Islet Transplant

 

In Vitro Fertilization includes guidelines for coverage. Hawaii providers who are contracted with HMSA bill for In Vitro services based on an all inclusive case rate. If services are rendered by a provider outside of the state of Hawaii or who does not participate with HMSA, medical records must be submitted with the claim. See In Vitro Procedures Requiring Documentation If Not Pre-certified

 

IV therapy. The following home IV therapies require pre-certification prior to the initiation of the therapy:

 

Knee Orthoses for Osteoarthritis

 

Kyphoplasty and Vertebroplasty

 

Laser Therapy for Plaque Psoriasis

 

Mental Health or Substance Abuse Residential Care Facility Services Outside the State of Hawaii

 

Naturopathic Services

 

Negative Pressure Wound Therapy (NPWT)

 

Nerve Fiber Density Testing

 

Occupational therapy. For PPO, HMO, EUTF, HSTA Plans (See Occupational Therapy - PPO, HMO, EUTF, HSTA Plans ) and for Federal Plan 087 (See Occupational Therapy - Federal Plan 87 )

 

Off-Label Drug Use

 

Organ transplants
Except kidney and cornea and clinical trials for certain organ transplants. Detailed information is available in specific transplant policies:

 

Orthodontic Treatment of Orofacial Anomalies

 

Oscillatory Device for Bronchial Drainage (The Vest)

 

Oxygen and Oxygen Equipment (for members 13 years of age and older).

 

Panniculectomy/Abdominoplasty

 

Physical therapy. For PPO, HMO, EUTF, HSTA Plans (See Physical Therapy - PPO, HMO, EUTF, HSTA Plans )and for Federal Plan 087 (See Physical Therapy - Federal Plan 87 )

 

Place of treatment exceptions
When a physician feels a procedure should be performed in a treatment setting other than where HMSA normally deems appropriate, pre-certification approval must be given by HMSA. (See Place of Treatment - Office and Place of Treatment - Outpatient )

 

Polysomnography - Sleep Studies

 

Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea

 

Post-acute and Residential Treatment Facility Stays

 

Post-acute, Residential Treatment Facility and Community Care Foster Family Home Care

 

Posterior Tibial Nerve Stimulation

 

Precertification Requirements - Akamai Advantage Plans

 

Preimplantation Genetic Diagnosis (PGD)

 

Pulmonary Rehabilitation

 

Pulse Oximeter for Children

 

Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

 

Radiology Guidelines for Advanced Imaging Studies

 

Reduction Mammaplasty for Breast-Related Symptoms

 

Repetitive Transcranial Magnetic Stimulation for Treatment Refractory Depression

 

Specialty Drugs Requiring Precertification

 

Speech Therapy Services/Rehabilitation

 

Spinal Cord Stimulators for Pain Management

 

Spinal Interventional Pain Management and Lumbar Spine Surgery

 

Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy

 

Subcutaneous Implantable Cardioverter Defibrillator (ICD) System

 

Surgeries, therapies or procedures employing new technology or representing a new application of existing technology.
(See Benefit Information)

 

Telehealth

 

Transcatheter Aortic-Valve Implantation for Aortic Stenosis

 

Transcatheter Closure of Patent Foramen Ovale for Stroke Prevention

 

Transcatheter Pulmonary Valve Implantation

 

Transcutaneous Electrical Nerve Stimulation (TENS)

 

Transplant Evaluations

 

Treatment of Varicose Veins

 

 

Criteria Used in Precertification Decisions

Evidence-based, scientifically established medical appropriateness criteria are used to make pre-certification decisions. Clinical criteria are reviewed annually by the HMSA Utilization Management Committee and are provided to all practitioners. Practitioners also may obtain criteria used for Medical Management decisions by writing to the Pre-certification Unit.

 

 

MM: December 2011

 

 

 


 

First Published:03/16/2007
Latest Revision:06/07/2017
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